Multimodality approach to renal and ureteric calculi

Transcription

1 58 lhe NATONAL MEDCAL JOURNAL OF NDA 11 Guastella G, Cefalsu E, Ciriminna R. One year experience with the GFT method. Acta Eur Fertill986;17:9l-7. 1 Nemiro JS, McGaughey RW. An alternative to in vuro fertilisation embryo transfer: The successful transfer of human oocytes and spermatozoa to the distal oviduct. Fertil Steri/1986;6: Wallach EE, Moghissi KS. Unexplained fertility. n: Berhma.n JJ, Kistner RW, Patton GW (eds), Progress in fertiliry. Toronto:Little Brown, 1988: Cohen MR. Treatment of endometriosis. n: nsler U, Lunenfeld B (eds), nfertility: Male and female. New York:Churchill Livingstone, 1986: S Belsey MA, Elliason R, Gal1egos AJ, Moghissi KS, Paulsen CA, Prasad MRN. Laboratory manual for the examifultion of human semen and semen ceryicai mucus interaction. Singapore:Press Concern, VOL.", NO. 16 Hinduja N, Anand Kumar TC. n vitro fertilization and embryo replacement in women. Nad Med J ndia 1988;1: Anand KumarTC, Puri CP, Gopalkrishnan K, Hinduja N. The in yilro fertilization and embryo transfer (VF-ET) and gamete intrafal10pian transfer (GFT) program at the nstitute for Research in Reproduction (CMR) and the King Edward Memorial Hospital, Parel, Bombay, ndia. J n Vitro Fen Embryo Transfer 1988;5: Veeck LL, Wortham JWE Jr, Witmyer J, et al. Maturation and fertilization of morphologically immature oocytes in a program of in vitro fertilization. Fertil Steri/1983;39: Yovich JL, Yovich 1M, Edirisinghe WR. The relative chance of pregnancy fol1owing tubal or uterine transfer procedures. Fertil Stuil988;9:8S8-6. Multimodality approach to renal and ureteric calculi R. K. AHLAWAT, A. TEWAR, M. BHANDAR, A. KUMAR, R. KAPOOR ABSTRACT Background. Minimal or non-invasivemethods for treating renal or ureteric calculi have reduced the incidence of open surgery in the West to less than 1%. Before using these methods routinely in ndia we need to take into account the social and economic needs of our patients and the costeffectiveness of the therapy. Methods. Over a period of 16 months we analysed the results of 596 renal units with renal and ureteric calculi managed by (a) extracorporeal shock wave lithotripsy, (b) percutaneous litholapaxy, (c) ureteroscopy, (d) open surgery and (e) various combinations of a, b, c and d. Results. Out-patient lithotripsy achieved a satisfactory outcome in pelvic (69% complete clearance, 1% minor residue), middle calyceal (8% complete clearance, 5% minor residue) and non-impacted ureteric calculi (93% complete clearance) with limited stone bulk. Percutaneous procedures had a better and quicker outcome than lithotripsy when the stone bulk was greater than 00 mm because it required a larger number of shock waves, repeated sittings and pre-lithotripsy stenting. Primary percutaneous debulking with adjunct lithotripsy for staghom calculi had a satisfactory outcome in 80% cases, while lithotripsy monotherapy usually failed. Percutaneous extraction resulted in a 95% success rate for large impacted upper ureteric calculi. Seventy-six per cent of ureteric calculi below the pelvic brim Sanjay Gandhi Postgraduate nstitute of Medical Sciences, Post Box No. 375, Raebareli Road, Lucknow 6001,lndia R. K. AHLAWAT, A. TEWAR, M. BHANDAR, A. KUMAR, R. KAPOOR Department of Urology Correspondence to R. K. AHLAWAT The National Medical Journal of ndia 1991 were retrieved using ureteroscopy alone. Open surgery either primarily or after failure of other modalities was offered to 6.% of the patients. t was the procedure of choice for large staghorn calculi with major stone bulk spread over various calyces, for multiple large pelvicajyceajcalculi, and for calculi associated with congenital anomalies. Conclusion. n ndia lithotripsy should only be used when a quick and satisfactory outcome is expected, otherwise an appropriate minimally invasive method or surgical stone removal should be advised. NTRODUCTON More than one-third of the patients admitted to urology departments in ndia have urinary calculi. Our referral centre records a higher incidence because it specializes in the treatment of calculus disease. Patients are now aware of minimal or non-invasive techniques for treating calculi and expect the urologist to select a treatment option which requires the shortest period of time away from work and also achieves satisfactory results. However, many of our patients in ndia seek medical opinion after they have had symptoms for several years and an increased duration of impaction results in secondary changes which make the non-invasive techniques less effective. (Obstructive uropathy causes up to 0% of end-stage renal disease in this country!.) The advent of percutaneous removal of stones in the late 1970s and ureteroscopy soon afterwards greatly influenced the management of calculus disease. Extracorporeal shock wave lithotripsy (ESWL) was introduced in the early and in the last few years this technique has been successful in removing calculi anywhere from the renal calyx to the bladder. n the West the incidence of

2 AHLAWAT et el. : MULTMODALTY APPROACH TO URNARY CALCUL open surgery for calculus disease has now been reduced to less than 1%. However, in ndia an appropriate strategy must be formulated carefully considering the cost-effectiveness of the various procedures, and the social and economic problems of our patients. The established western indications for the lesser invasive methods to treat kidney and ureteric stones need careful appraisal when applied to developing countries. Though we have a complete range of the latest equipment to treat stones, the management has often to be guided by the poverty of our patients and their need for a short convalescence. This retrospective study was aimed at defining an appropriate treatment strategy to include endourology, open surgery and lithotripsy. PATENTS AND METHODS Five hundred and ninety-six renal units with calculus disease were treated at our centre between October 1988 and January The modalities used were ESWL, percutaneous nephrolithotomy (PCN), ureteroendoscopy (URS) and open surgery. All ESWL and endourological procedures were done after obtaining informed consent from the patient and only after he (or she) was willing to undergo staged treatment. The patient also had to accept a possible failure and be willing to undergo alternative procedures in the event of failure. Extracorporeal shock wave lithotripsy ESWL (n=369) was done as an out-patient technique without anaesthesia, except in children and in patients with ureteric calculi who required pre-eswl endoscopic manoeuvres. The indications for pre-eswl stenting were: Presence of chronic renal failure, Bilateral disease, Stones greater than 00 mm-, Solitary kidney, Patients who came from great distances and were unable to come for frequent follow up, and 6. Those with relatively radiolucent ureteric calculi which lay against bone. A maximum of 3500 shock waves (SWs) at kv were given in one sitting. The second sitting was usually conducted after days. Patients were given diclofenac and an antibiotic during and after treatment. f the calculus could not be fragmented or fragmentation of only a small part «10%) was achieved in two sittings the patient was switched to an alternative treatment modality. Progress was monitored at, and 6 weeks with abdominal X-rays. Fragments larger than 5 mm in diameter were treated similarly during follow up visits. Auxiliary PCN or URS was done for sepsis, unabated pain, or persistent fragments in the ureter after 3 months. Percutaneous nephrolithotomy Percutaneous procedures (n=101) were done under C-arm fluoroscopic control after opacification of the urinary system with a preplaced ureteric catheter, unless the site of entry (posterior middle calyx or inferior calyx) was 59 already marked by a stone seen on intravenous pyelogram. The tract was dilated with metal or teflon dilators and an amplatz sheath was used. Distilled water was used for irrigation, but substituted with 116saline when electrohydraulic (EHL) energy was applied. The procedure was usually done in a single stage. Two-stage procedures were done in patients with initial non-functioning units and in patients presenting with sepsis or acute-on-chronic renal failure, when the second stage was delayed by 3 to 6 weeks. Plain X-rays of the abdomen and nephrostograms were done on the third postoperative day and a re-look through the same tract (or a fresh procedure) performed, if necessary, on the fourth or fifth day. Stones in unapproachable calyces (the upper or anterior calyces are not entered by a rigid nephroscope) were subjected to auxiliary ESWL. Stones up to cm in size were recovered by a single pick, while those greater than em were first disintegrated by ultrasound (US) or EHL energy. Ureteroendoscopy While almost all lower ureteric calculi were subjected to ureteroscopy, only selected calculi proximal to the pelvic brim (those in thin subjects and females) were chosen for this procedure. Ureteroscopies (n=76) were done with a 1 F integrated ureteroscope (Storz, Germany) using distilled water as irrigating fluid through a Ureteromat (hydraulic pressure device). The opposite hip was extended and the knee flexed while the ipsilateral limb was kept in the standard lithotomy position. The bladder was entered directly by the ureteroscope and a feeding tube was placed by its side to keep the bladder empty. The ureteric meatus was identified and a ureteric catheter was passed 1 to em beyond the meatus before guiding the scope into the ureter keeping the Ureteromat flow pressure at 00 mm Hg. After bypassing the intravesical ureter, the pressure was reduced. The ureteroscope was advanced to the stone and smooth stones up to 1 em in diameter were removed. Bigger or branched stones were disintegrated with US or EHL energy prior to removal. Floating fragments were bypassed with a ureteric catheter to allow spontaneous passage. When the approach to the stone was difficult, it was bypassed by a ureteric catheter. f even bypass failed, the ureteric catheter was guided up to the stone and left in situ attached to a urethral catheter. Some of these patients were treated with ESWL, while others had a repeat URS after 3- days. One to three days after the procedure, a plain X-ray of the abdomen with a ureterogram was done after which the catheter was removed. t was exchanged for a stent, if large fragments remained, and kept in situ for to 6 weeks depending on the clearance. Open surgery For renal and upper ureteric calculus disease open surgery was performed through a lumbar incision. The primary indications for open surgery were: 1. Complex staghorns,. Multiple pelvicalyceal calculi,

3 60 THE NATONAL 3. Calculi associated with a. advanced renal failure (serum creatinine >6 mg/l00 ml) b. congenital anomalies such as horseshoe kidneys and pelviureteric junction (PUJ) obstruction (with a large pelvis and high ureteral insertion),. A poor patient, and 5. Patients who refused staged treatment. Secondary indications for open surgery were failures and complications of other non-operative methods. All patients had intravenous pyelography following apparent clearance, or at the end of 3 months, whichever was earlier, to assess the renal function and evaluate the clearance of the urinary tract. Clearance was classified into total clearance and the presence of non-obstructing fragments smaller than 3 mm in diameter. Both were accepted as satisfactory outcomes. Residual stones larger than 3 mm or greater than 10% of the original stone bulk were categorized as failures of treatment and were treated by alternative modalities. The auxiliary treatment rate, complications and mortality were recorded. RESULTS Almost two-thirds of the 596 treated units had a solitary pelvic (0) or ureteric (186) calculus (Fig. 1) while 13% (76) had calculi at multiple sites. One of every ten units (58) had compromised renal function (serum creatinine > 1.8 mg/l00 ml). MEDCAL JOURNAL VOL., OF NDA NO. Stting. (avg.) SZE mm (n) i;:;;;;;~~t---'--"--, 100 (10) (71) 8-00 (H) '.7-00 (8) o SE'J 8 Shock _vel Shock _vel (avg.) 8 1 (avg.) _ Slttl"" (avg.). Pelvic calculi: Stone bulk and requirement of shock waves for disintegration and number of sittings given FG of 17 (91%) evaluable patients at the end of 3 months and was independent of the stone size (Table ). Patients with large pelvicalyceal systems (PCS) with a dilated inferior calyx (n=6o) had a residue rate (minor stone gravel in the dependent calyx) of 35% (1) compared to 8% (7 of 87) when the PCS was normal. Post-ESWL auxiliary procedures (PCN or URS) were required in 3.% (5) of the cases. Calculi at all other sites, when compared size for size with pelvic calculi, required a higher number of SWs (Fig. 3). The clearance rate in the middle calyx (n=1) Pelvic 0 SHOCK WNES (thoulanda) 3% Ureteric 186 Stag horn 1 31% 7 FG 1. Site distribution o 3. ESWL: Shock wave requirement of calculi with similar stone bulk ( mm) at various sites FG Pre-ESWL 'double J' (D-J) stenting Pre-ESWL O-J stenting was done in 39% (1) of the treated patients. The complications encountered were displacements (downward or upward) in 1% (17), flank discomfort in 36% (51), terminal dysuria and haematuria in 60% (85) and broken stents in 1% (1). Obstructive or septic complications were not seen in stented patients but occurred in 8% (19) of non-stented cases. Extracorporeal shock wave lithotripsy There was a solitary pelvic calculus in 17 renal units. The SW requirement depended directly on stone bulk (Fig. ). Pelvic calculi bigger than 00 mm- required an average of 9700 SWs and an average of 3. sittings besides preeswl stenting. Satisfactory outcome was achieved in 133 was similar to that for pelvic calculi but despite good fragmentation, total clearance from the upper (n=15) and inferior (n=5) calyces was poor (8 out of 1 evaluable, 57%; and 6 out of evaluable, 6% respectively) with a high incidence of small residue. (Table ). The average stone mass treated at various calyces was similar (168, 13 and 156 mrn- at the upper, middle and inferior calyx). None of the staghorns (n=8) treated with ESWL alone had a successful outcome. The stone bulk in these cases ranged from 00 to 598 mrn! (average 106 mm-), All these patients had to be treated with alternative modalities. Multiple pelvicalyceal calculi (n=3, average stone bulk 331 mm-) had a satisfactory outcome in 81% cases with total clearance in 57% (1/1; minor residue 5, %).

4 AHLAWAT elll/. : MULnMODALTY APPROACH TO URNARY CALCUU 61 TABLE. Treatment results of ESWL for pelvic calculi Satisfactory outcome. Failure Bulk Treated Evaluated at Cleared (A) Minor A+B mm 3 months residue (B) n n n("a) n("a) ("a) Major Unfragmentable (D) C+D residue (C) n("a) n("a) ("a) > (69) (31) (67) 13() (69) 11 (1) 90 < (73) 3(1) (8) (3) 11 5 (10) (9) 9 TABLE. Treatment results of ESWL for renal calculi Satisfactory outcome Failure Site Treated Evaluated at Cleared (A) Minor A+B 3 months residue (B) n n n("a) n("a) ("a) Pelvic (69) 31 (1) 90 nf.calyx 5 6(6) 10() 86 Mid. calyx (8) 1 (5) 89 Sup. calyx (57) 5(36) 93 Pelvicitlyceal (57) 5() 81 Staghoms nf nferior Mid Middle Sup Superior There was no correlation between stone bulk and ultimate outcome at any ofthese sites, though 86% ofthese treated units had a stone.bulk less than 00 mm (average cross dimension 0 mm) and only.% units had a stone bulk of greater than 65 mm! (average cross dimension 5 mm). Ureteric calculi treated in situ (n=67) had a satisfactory outcome in 76% (51) cases, while those manipulated endoscopically and bypassed successfully (n=) before being subjected to ESW had a total clearance rate of 91% (0). Fifty-nine per cent of the patients with ureteric calculi had had symptoms for more than 6 months and many had moderate to severe hydronephrosis at the time of presentation. f impacted ureteric calculi were excluded, a satisfactory outcome was achieved in 93% (5/7) ofthe patients (Fig. ). Percutaneous nephrolithotomy Primary pen for pelvic calculi was done in cases (Table ). The average stone bulk (7 mm) was significantly greater than that of calculi treated with ESWL (65 mm). Total clearance was achieved by pen alone in 71% (17). When combined with ESWL, a satisfactory outcome was achieved in 96% ( out of 3; in 1 the procedure was abandoned because of excessive bleeding). Total clearance was also achieved in 7 inferior calyceal calculi (average size 306 mm') treated with pen. n two cases with calyceal calculi and suspected pelviureteric junction obstruction, endopyelotomy was done (the post-pen pelvic flow pressure test-whitaker test-showed a high pressure in the pes). The intrapelvic pressure was reduced after endopyelotomy. Of the 1 staghorn calculi (average size 109 mm) treated percutaneously, a satis- Major Unfragmentable (D) C+D residue(c) n("a) n("a) ("a) 10(7) (3) 10 (5) (9).1 (11) (7) 7 (9.5) (9.5) (100) 100 TABLE. Treatment results with pen Outcome Site Evaluated Cleared Minor Failure Adjunct at3months residue ESWL n n n(%) n("a) n("a) n("a) Pelvic 3 18 (78) (18) 1 () 7(9) Calyceal 7 7 6(86) 1 (1) 0 0 Staghorns 1 0 5(5) 11 (55) (0) 1 (67) Pelvicalyceal (50) 10(36) (1) 11 (38) Upp. ureteric (90) 1 (5) 1 (5) 1 (5) Upp Upper URETERC ESWL: MANlltULATON ~ r-~==~======= , "''''''OWL 1111 n tu ESWL: DEGREE OF.MfWmON HDN-MocL "'''';:~~,.?;t''t~'''''~ ee.,» / ~~ ~~, :;,~;,~{&,", 'i~ v"~i Fro. ESWL clearance of ureteric calculi: mpact of pre- ESWL manipulation status and obstructive changes in PCS representing degree of impaction

5 6 THE NATONAL MEDCAL JOURNAL OF NDA factory outcome was obtained in 16 (80%; PCN alone 7; PCN and ESWL 9). PCN clearance in multiple pelvicalyceal calculi (n=9, average 657 mm) was comparable to ESWL, but 38% (11) of stones in the anterior or superior calyces had to be treated with ESWL as well. Clearance was achieved in 95% (19 out of 0) of impacted large upper ureteric calculi (Table ). TABLE V. Morbidity associated Procedure ESWL PCN n with various procedures Complications 369 sepsis obstructive pyonephrosis 101 injuries haemorrhage n(%) { Ureteroscopy Ureteroscopy was successful in retrieving 76% of distal (31 out of 5) and 1% of proximally located (9 out of ) ureteric calculi. Ureteric oedema distal to the stone, due to prolonged impaction at the site, was often encountered, n these patients, the stone could sometimes be seen through the narrowed lumen but it was not possible to traverse the area of oedema with the rigid instrument. Prolonged impaction also resulted in kinking of the ureter just distal to the stone and a rigid instrument could not straighten this as it had become fixed by periureteritis. Using adjunct ESWL, a satisfactory outcome was achieved in 18of (83%) upper and 50 of 5 (93%) lower ureteric calculi. Open surgery Open surgery was performed in 38 renal units (6 pelvic, 15 staghom, 9 pelvicalyceal and 8 ureteric calculi). t was the primary procedure in 3 (Table V) and was done after failure of PCN/ESWL and URS in patients. Lumbotomy was done in 1, ureterolithotomy in and a standard extended pyelolithotomy in. Staghom residues TABLE V. Primary indications for open surgery n Horseshoe kidneys Pelviureteric junction obstruction Large volume pelvicalyceal calculi Large staghoms Economic indications after open surgery needed auxiliary procedures in % of cases. This was because most of the open procedures were done in kidneys with small intrarenal pelves and multiple secondary calculi in the peripheral calyces. Two-thirds of this population had chronic renal failure and other associated complications such as diabetes or hypertension, making them poor risks for prolonged surgery. The auxiliary procedures done were ESWL in and PCN in 3. A satisfactory outcome was achieved in all except staghom and pelvicalyceal calculi. Complications Major complications such as sepsis and obstruction (Table V) followed ESWL in 19 (5.%) of the cases and were managed with adjunct URS or PCN. Two renal units which developed pyonephrosis post-eswl were subjected to nephrectomy, as function failed to recover despite adequate drainage with PCN. Fifteen per cent of per- VOL., NO. perinephric abscess extrarenal URS 76 ureteric perforation Open surgery 38 prolonged urinary leak Salvage ~ (5.) PCNURS nephrectomy (0.5) 11(10.9) conservative (3.9) -conservative -embolization 1(0.9) percutaneous drainage (3.9) second stage retrieval (5.3) ~xploration -PCN/stenting 3 (7.9) conservative cutaneous procedures had major complications (major pelviureteric injuries 11, haemorrhage ). All were satisfactorily managed with nephrostomy for -5 days except for cases with bleeding who required selective embolization of the bleeding vessel. While smaller than 3 mm extrarenal stone residues did not cause any morbidity, those greater than 3 mm were removed successfully in patients on subsequent sittings. One patient developed an infected perinephric collection after removal of the percutaneous tube which healed after drainage. After open surgery 3 (7.9%) cases had a urinary leak for more than 7 days and were managed conservatively. Four cases undergoing URS had ureteric injuries of which were explored immediately and were managed by initial PCN followed by D-l stenting a week later (antegradel retrograde combined) which was left indwelling for to 5 weeks. No ureteric injuries occurred during the last 8 months. No renal units were lost following PCN, URS or open surgery. The average hospital stay after ESWL was 0.8 days (both for primary and auxiliary procedures), 3. days after URS and 5. days after PCN. The average hospital stay after open surgery was 10.3 days. Three patients (0.5%) died; one each following ESWL, PCN and open surgery. One patient with a previous history of myocardial infarction was subjected to ESWL for an inferior calyceal calculus; after discharge from the hospital he was found dead at home next morning. The other tw.opatients died in hospital within hours of the procedures, one after acute myocardial infarction and the other from causes unknown. DSCUSSON Besides the size and site of a renal or ureteric stone, its constituents, the degree of hydronephrosis, whether or not it is impacted and the functional status of the kidney are important factors which have a bearing on the choice of therapy. The other key factors in our country are the expected number of procedures, the duration of hospital stay and the closeness of follow up required. We feel it is important to be completely honest with the patient before performing ESWL or endoscopic procedures. He should be clearly told about the failure rate and

6 AHLAWAT et a. : MULTMODALlY APPROACH TO URNARY CALCUL never promised success in a single stage or by a single technique. Our experience indicates that while 90% of pelvic calculi clear satisfactorily after ESWL, large stones (>00 mrn-) require a large number of SWs and thus have a high re-treatment rate. n addition pre-eswl stenting, if required, prolongs the treatment period causing patient dissatisfaction. Presently we advocate ESWL as primary therapy for all calculi greater than 00 mm-, especially if they are not very dense, and are associated with a normal collecting system. n other situations (large stone bulk, dilated peripheral calyces and suspected distal obstruction), we suggest PCN as has been advised by other authors." Symptomatic calyceal calculi have always been a problem. Calyceal colic, formerly unrecognized, is now considered to be a distinct entity' and is likely to improve following disintegration with lithotripsy, irrespective of whether or not the calyces are cleared. Even asymptomatic calyceal calculi have been subjected to ESWL treatment. Calyceal calculi are also not easy to remove through the percutaneous route. Tracts tend to form and upper calyceal calculi may need supracostal punctures which may result in pulmonary cornplications.> However, once the tract is stable, calyceal calculi smaller than l.5 em in diameter can be removed by a single pick. Those associated with doubtful PU} obstruction are ideal for PCN. 3 Both removal of the stone and endopyelotomy may be done if the approach is through an appropriate calyx. Presently we only treat symptomatic calyceal calculi. All patients with calculi in the middle and upper calyces and those in non-dilated inferior calyces are advised ESWL. Upper calyceal calculi are neither easy to disintegrate by ESWL nor are they easy to remove by PCN. The presence of a dilated inferior calyx, which would facilitate percutaneous tract dilatation, is one of our indications for adopting the percutaneous approach. 6 We have been disappointed with ESWL monotherapy for staghorn calculi, although it has been used successfully by others.v' The screening effect of the fragmented peripheral bulk stops the SWs from reaching the centre of the calculus and results in a non-fragmented pelvic core." n our experience, PCN should be the primary choice in these cases. The incidence of complications with PCN in staghorn calculi is not higher than that when the technique is used for solitary calculi. n some cases where the stone completely occupied the calyx to be entered, we treated the stone mass with ESWL primarily and this made tract formation easier." We use PCN for staghorns with a large pelvic mass as the major part can be debulked, and often complete removal is possible through a single percutaneous tract. \0 For those calculi with a small pelvic mass and the major portion deep in the various calyces, open surgery is the best choice. Some lean staghorns in non-dilated systems may still be successfully treated by ESWL, but this situation is rare. Calculi throughout the length of the ureter can be treated with ESWL by second generation lithotripters in either the prone or supine positions The whole ureter can also be traversed by a ureteroscope, though negotiating the instrument beyond the iliac vessels is not always 63 successful. We divide the ureter into two parts, above and below the iliac vessels. Both are amenable to ESWL, while ureteroscopy is more successful in extracting stones in the lower part, the proximal ureter can also be approached percutaneously and is a common site of large impacted ureteric calculi. Non-impacted ureteric calculi are also amenable to treatment with in situ ESWL. We feel that other calculi should be treated by endoscopic manipulation after ESWL to ensure a good success rate. Our poor results compared to those reported in the literature are because almost half our patients with ureteric calculi have had symptoms for more than 6 months. This probably results in stone impaction making it more difficult to remove them by ureteroscopy.'! Higher success rates might be achieved with flexible, small calibre instruments and laser energy. 1 The percutaneous approach to large, impacted upper ureteric calculi with proximal hydronephrosis even in the presence of secondary renal calculi has been rewarding and has resulted in the clearance of stones in more than 90% of patients-the best results reported in this situation We presently advocate URS for lower ureteric stones with an ESWL back up, and ESWL as the primary treatment for patients with a short history of non-impacted proximal ureteric calculi. We prefer PCN for large and/or impacted upper ureteric calculi. Open surgery was offered to 6.% of our cases. t is still the treatment of choice for complex staghorn and multiple pelvicalyceal calculi, when a quick recovery is important and frequent visits to the hospital are not possible; as well as for stones associated with congenital anomalies. 17 Most such patients can be sent back to work earlier after open surgery than after staged endourological and ESWL treatment which requires multiple hospital visits and admissions. Such considerations are important to many of our patients whose livelihood is based on daily wages. The problem of 'residual' calculi remains unresolved. Studies have indicated that small fragments {even from infected staghorns) may be sterilized in the urinary system with appropriate antibiotic therapy, putting to rest earlier contentions that complete clearance of staghorns is necessary before infection can be controlled. S However, even in the absence of infection, it has been reported that the re-growth rate is higher in patients with residual stones than in those with complete clearance." Medical treatment is thus necessary for all small «3 mm) residues,'? while procedures such as PCN should be used for larger stones. Patients coming to our centre for treatment of their stone disease have high expectations of ESWL for which they invest many years of savings. We believe that it is important to clearly explain to them the problems associated with ESWL and tell them that the technique is not suitable in many situations (Figs. Sa and 5b). There is an initial morbidity even with successful and wellperformed endourological or open surgical procedures but the results are quick and they were gladly accepted by our patients after the pros and cons of other procedures had been explained to them. The prolonged morbidity on account of repeated treatments, residual calculi, the long

7 6 THE NATONAL MEDCAL JOURNAL OF NDA VOL., NO. STE BULKmm DLATATON OFPCS PRMARY CHOCE RENAL CALCUU Pelvic Stags with Multiple MidlUpper pelvic bulk calyceal calyceal Pelvlcalyceal involvement Proximal nfcalyceal Non-impacted <00 >00 >00 Mild Gross Gross ESWL PCN Open" " also primary choice in patient not willing for staged treatment and when indicated economically n-situ ESWL Large PCN URETERC CALCUL i mpacted j' ) BypassPush-bSck ESWL Distal URETEROSCOPY Failure FG Sa. Suggested protocol for management of renal calculi FG 5b. Suggested protocol for management of ureteric calculi period of waiting before clearance of fragments following monotherapy with ESWL offset the advantage of its being the least invasive modality. Thus ESWL should be tried only when a quick and satisfactoryoutcome is probable. REFERENCES Chugh KS. Singhal PC. Nath VS. et al. Chronic end stage renal disease at Chandigarh: Prevalence and problems of management by dialysis and transplantation. Proceedings of the first Asian Pacific Conference of Nephrology Haupt G. Haupt A. Donovan JM. Drach GW. Chaussy C. Short term changes of laboratory values after extracorporeal shock wave lithotripsy: A comparative study.} Uro1989;11:S~. 3 Leroy AJ. Segura JW. Williams HJ Jr. Patterson DE. Percutaneous renal calculus removal in extracorporeal shock wave lithotripsy practice.z Uro/1987;138: Mee SL. Thuroff JW. Small calyceal stones: s extracorporeal shock wave lithotripsy justified.j' Uro1988;139:908-O. 5 Winfield HN. Clayman RV. Chaussy CG. Weyman PJ. Fuchs GJ, Lupu AN. Monotherapy of staghom renal calculi: A comparative study between percutaneous nephrolithotomy and extracorporeal shock wave lithotripsy.t Uro1988;139: Lingeman JE. Current concepts in the relative efficacy of percutaneous nephrostolithotomy and extracorporeal shock wave lithotripsy. World} Uro/1987;5: Michaels EK, Fowler JE Jr. ESWL monotherapy for large-volume renal calculi: Efficacy and morbidity. Urology 1989;3: Whelan JP. Finlayson B. Use ofretrograde lavage catheter during ESWL treatments. Urology 1989;33:31~. 9 Fuchs GJ. Chaussy CG. Extracorporeal shock wave lithotripsy for staghom stones: Reassessment of our treatment strategy. World} Uro1987;5: di Silverio F, Gallucci M. Alpi G. Staghom calculi of the kidney: Classification and therapy. Br Uro/l990;65: Holden D. Rao PN. Ureteral stones: The results of primary in situ extracorporeal shock wave lithotripsy.} Uro1989;11: Grace PA. Gillen P, Smith JM. Fitzpatrick JM. Extracorporeal shock wave lithotripsy with the lithostar lithotripter. Br ] Urol 1989;6: Dretler SP. Weinstein A. Modified algorithm for management of ureteral calculi: 100consecutive cases. } Uro/1988;0: Beck EM. Vanghan ED Jr. Sosa RE. The pulsed dye laser in the treatment of ureteral calculi. Semin Uro1989;7: Anselmo G. Bassi E. Fandella A, et al. Antegrade ureterolithotomy in the treatment of obstructing or incarcerated proximal ureteric stones. 8r} Uroll990;65: Riehle RA Jr. Endoscopy for ureteral stones in the age of extracorporeal shock wave lithotripsy. Semin Uroll989j7: Assimos DG. Boyce WH. Harrison LH. et al. The role of open stone surgery since extracorporeal shock wave lithotripsy. } Urol 1989;11: Michaels EK. Fowler JE Jr. Mariano M. Bacteriuria following extracorporeal shock wave lithotripsy of infection stones. } Urol 1988;10:~. 19 Preminger GM. Management of residual stones. n: Rous SN (ed). Stone disease: diagnosis and management. Florida:Grune and Stratton. 1987:33.